Efficacy of Group versus Individual Relapse Prevention Therapy on Alcohol Intake and Quality of Life in Individuals with Alcohol Use Disorder

INTRODUCTION 

The widespread abuse of Alcohol has become a human tragedy. Each year the abuse of alcohol exact an enormous toll in deaths, decline in productivity, more crime and accidents and also increased expenditure in rehabilitation. The word “alcohol” came from the Arabic “Alkuhl” meaning essence. A proposed definition of alcohol use is a “primary chronic disease with genetic, psychological and environmental factors influencing its development and its manifestation. The disease is often progressive and fatal. 

The recognition of alcoholism as a disease occurred during the early 1950s by the World health Organization (WHO) Jellinek’s description of “disease concept of alcoholism” and the subtypes of alcoholism generated a lot of interest. It proved to be stimulus for systematic descriptions of alcohol related problems. The first description of “Alcohol Dependence Syndrome” in 1976 by Edwards and Gross emphasized inability to control consumption, salience of drink seeking behavior, and narrowing of drinking repertoire as the characteristics besides the phenomena of tolerance and withdrawal. 

Addiction is conceptualised as a chronic relapsing brain disorder. Miller and Hester reviewed more than 500 alcoholism outcome studies and reported that more than 75% of subjects relapsed within 1 year of treatment (Miller & Hester, 1980). A study published by Hunt and colleagues demonstrated that nicotine, heroin, and alcohol produced highly similar rates of relapse over a one-year period, in the range of 80-95% (Kirshenbaum et al., 2009). A significant proportion (40–80%) of patients receiving treatment for alcohol use disorders have at least one drink, a “lapse,” within the first year of after treatment, whereas around 20% of patients return to pre-treatment levels of alcohol use (Steckler et al., 2013). Relapse prevention (RP) is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours (Marlatt & Witkiewitz, 2005).The initial transgression of problem behaviour after a quit attempt is defined as a “lapse,” which could eventually lead to continued transgressions to a level that is similar to before quitting and is defined as a “relapse”. Another possible outcome of a lapse is that the client may manage to abstain and thus continue to go forward in the path of positive change, “prolapse” (Marlatt & Witkiewitz, 2005). Many researchers define relapse as a process rather than as a discrete event and thus attempt to characterize the factors contributing to relapse (Steckler et al., 2013). Relapse prevention therapy (RPT) along with pharmacotherapy is the mainstay treatment after management of acute alcohol withdrawal syndrome in Alcohol use disorder. However, deficiency of trained mental health professionals in India is a significant problem in provision of psychosocial interventions which is time consuming and hence, there is need for adoption of alternate modalities to increase efficiency of psychosocial interventions. One of the methods is providing psychosocial intervention to a number of clients at same time. Group therapy has become popular because it is more efficient and costs less than individual treatment. 

Treating adult clients in groups has many advantages, as well as some risks. Any treatment modality- group therapy, individual therapy, family therapy, and medication can yield poor results if applied indiscriminately or administered by an unskilled or improperly trained therapist. The potential drawbacks of group therapy, however, are no greater than for any other form of treatment. 

Some of the numerous advantages to using groups in substance abuse treatment are described below (Brown and Yalom 1977; Flores 1997; Garvin unpublished manuscript; Vannicelli 1992).  Groups provide positive peer support and pressure to abstain from substances of abuse. Unlike AA, and, to some degree, substance abuse treatment program participation, group therapy, from the very beginning, elicits a commitment by all the group members to attend and to recognize that failure to attend, to be on time, and to treat group time as special disappoints the group and reduces its effectiveness. Therefore, both peer support and pressure for abstinence are strong. Groups reduce the sense of isolation that most people who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with the same issues. Although AA and treatment groups of all types provide these opportunities for sharing, for some people the more formal and deliberate nature of participation in process group therapy increases their feelings of security and enhances their ability to share openly. Groups enable people who abuse substances to witness the recovery of others. From this inspiration, people who are addicted to substances gain hope that they, too, can maintain abstinence. Furthermore, an interpersonal process group, which is of long duration, allows a magnified witnessing of both the changes related to recovery as well as group members’ intra and interpersonal changes.

Groups help members learn to cope with their substance abuse and other problems by allowing them to see how others deal with similar problems. Groups can accentuate this process and extend it to include changes in how group members relate to bosses, parents, spouses, siblings, children, and people in general. Groups can provide useful information to clients who are new to recovery. For example, clients can learn how to avoid certain triggers for use, the importance of abstinence as a priority, and how to self identify as a person recovering from substance abuse. Group experiences can help deepen these insights. For example, self identifying as a person recovering from substance abuse can be a complex process that changes significantly during different stages of treatment and recovery and often reveals the set of traits that makes the system of a person’s self as altogether unique. Groups provide feedback concerning the values and abilities of other group members. This information helps members improve their conceptions of self or modify faulty, distorted conceptions. In terms of process groups in particular, as specific themes emerge in a client’s group experience, repetitive feedback from multiple group members and the therapist can chip away at those faulty or distorted conceptions in slightly different ways until they not only are correctable, but also the very process of correction and change is revealed through the examination of the group processes. Groups offer family like experiences. Groups can provide the support and nurturance that may have been lacking in group members’ families of origin. The group also gives members the opportunity to practice healthy ways of interacting with their families.

MATERIALS AND METHODS

Aims and Objectives: To compare the efficacy of group based relapse prevention therapy versus individual based relapse prevention therapy on alcohol intake and Quality of Life in Alcohol use disorder. 

Sample and Sampling: Subjects who diagnosed as per the criteria for substance dependence according to International Classification of Disease, 10th revision, Diagnostic Criteria for Research (ICD- 10 DCR) and given consent to participate in the study were recruited.  Subject with a family history of mental illness, mental retardation, epilepsy and physical illness and substance use or any other co-morbid psychiatric condition like – multiple substance dependence, mental illness, mental retardation, epilepsy and physical illness were excluded. A total number of 30 patients were randomized to group based RPT (15) and individual based RPT (15) from the out-patient Department of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, India, using systematic random sampling. The two RPT formats were identical in content, consisting weekly session for 12 weeks. Both the groups were provided routine pharmacological treatment. Primary measure outcome were abstinence and relapse rates and secondary outcome measures were treatment compliance and WHO Quality of Life (BREF) (WHO, 1996)- The WHOQOL-BREF has been developed by the WHOQOL Group to provide a short form QOL assessment that looks at domain level profiles, using data from the WHOQOL-100. It is based on a four domain structure. Each domain covers several aspects of individual’s life. The WHOQOL-BREF contains a total of 26 items. The range of score in each item is between 1 and 5, with higher scores denoting higher QOL levels. The Cronbach’s alphas for the QOL scale and subscales as resulted in this study have ranged between .67 (for the 3 items of socialrelations) and .93 (for the 24 items total scale).

TYPES AND TECHNIQUES OF INTERVENTION

Psychoeducation: The patients and their family members offered psychoeducation to make them aware about the nature of illness, course, treatment, prognosis and to Clearfield any misconceptions. This was done so that the patients got a better position to deal with the illness as they had no hope of getting better. Directions to reduce repeated medical consultations and investigations also provided.

Supportive Psychotherapy: It was aimed at validating the distress of the patients and their family members who are undergoing treatment. The patients and their family members are given reassurance, support and his ability to cope with distress are reinforced. 

Relapse Prevention Therapy:  It was carried out with four sessions for 12 weeks. Each session was continued for 45-60 minutes and delivered in the individual and group setting with the aim to establish a firm therapeutic alliance with the patients, to maintain abstinence and increase relapse rates and to educate about the future compliance and treatment adherence as well as to improve overall quality of life.

Sessions Framework

First Session: In the first session psychoeducation was done with detailed discussion about alcohol dependence, the therapist provided to the patient with clear feedback of their drinking, frequency, intensity negative consequences and risk factors.

Second Session: The commitment to leave the substance was strengthened and guilt was induced and ill effects of the substance and their effects on all domains of life were discussed. In this session cost/benefit analysis was done. The idea that consequences can be negative or positive is central to allowing for an open, non-defensive examination of the role of substances in the group member’s lives.   

Third Session: In this session, the craving was discussed. Such as environmental cues, stress, mental illness and withdrawal symptoms which lead to craving if clients associate use with relief of these symptoms. In this session coping skills i.e. distraction techniques, coping card, sober were also taught. In this assertiveness training skills were also discussed.

Fourth Session: Patients were reviewed.  In this session, they were also educated about followup and medical adherence. During this session the patients gave feedbacks and unclarified concepts and its intervention strategies and the therapist does corrections and clarifies all concepts.  After the session therapist explained to patients the importance of the regular practice of interventions guided in all sessions.

RESULTS

Table 2 suggests after individual RPT majority of patients with alcohol dependence syndrome (ADS) remains abstinence for 10-30 days but on the other hand after group RPT abstinence period of patients with alcohol dependence syndrome is increased upto 60 or more days.

Table 3 reveals the comparison of individual RPT and group RPT in terms of relapse rate, result suggests that relapse rate was found low (12) in group RPT as compared to individual RPT (10). 

Table 4 reveals the comparison of compliance of patients after having individual RPT and group RPT, result shows that majority of patients with ADS were ambivalent in following compliance but on the other hand after group RPT maximum of patients have good compliance.

Table 5 shows the mean differences between Individual RPT and Group RPT in terms of quality of life. Results explains that in social relationship, psychological and physical quality of life mean score was found high in group RPT than individual RPT at .01 significant level. Similarly Physical quality of life of patient with alcohol use disorder was found high after group RPT than Individual RPT.  In total quality of life group RPT scores are more than individual RPT.

DISCUSSION

Present study was aimed to compare the efficacy of group based relapse prevention therapy versus individual based relapse prevention therapy on alcohol intake and Quality of Life in Alcohol use disorder. Total numbers of 30 patients were randomized to group based RPT (15) and individual based RPT (15) from the out-patient Department of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, India, using systematic random sampling. The two RPT formats were identical in content, consisting weekly session for 12 weeks. Both the groups were provided routine pharmacological treatment. Primary measure outcome were abstinence and relapse rates and secondary outcome measures were treatment compliance and WHO Quality of Life (BREF) (WHO, 1996). 

Results indicates primary measure outcome such as increased abstinence and reduced relapse rates in both the groups but it was found significantly high in group based RPT and as well as some secondary outcome measures such as treatment compliance and Quality of Life were increased in group based RPT.

In a subsequent meta-analysis by Irwin et al., (1999), twenty-six published and unpublished studies representing a sample of 9,504 participants were included. Results indicated that RP was generally effective, particularly for alcohol problems. Additionally, outcome was moderated by several variables. Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment. Moderation analyses suggested that RP was consistently efficacious across treatment modalities (individual vs. group) and settings (inpatient vs. outpatient).

In a study by McCrady (2000) evaluating the effectiveness of psychological interventions for alcohol use disorder such as Brief Interventions and Relapse Prevention was classified as efficacious.

CONCLUSION AND RECOMMENDATIONS

Relapse prevention (RP) is a cognitive- behavioural approach with the goal of identifying and addressing high-risk situations for relapse and assisting individuals in maintaining desired behavioural changes. RP has two specific aims:

1. Preventing an initial lapse and maintaining abstinence or harm reduction treatment goals.

2. Providing lapse management if a lapse occurs such that further relapses can be prevented (Marlatt & Witkiewitz, 2005).

Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies. The assumption of RP is that it is problematic to expect that the effects of a treatment that is designed to moderate or eliminate an undesirable behaviour will endure beyond the termination of that treatment. Further, there are reasons to presume a problem will re-emerge on returning to the old environment that elicited and maintained the problem behaviour for instance, forgetting the skills, techniques, and information taught during therapy; and decreased motivation Brunswig et al., (2002). Inspite RPT Substance abuse treatment professionals employ a variety of group treatment models to meet client needs during the multiphase process of recovery. Five group therapy models that are effective for substance abuse treatment: • Psycho educational groups • Skills development groups • Cognitive–behavioral/problem solving groups • Support groups • Interpersonal process groups. There is some  limitation of the present study that being a time bound study only a small sample could be taken and hence the generalization of the result remains doubtful and the study does not aim at generalisation as the sample is not representative.

References

Brown, S., & Yalom, I.D. (1977). Interactional group therapy with alcoholics. Journal of Studies on Alcohol, 38(3), 426–456.

Brunswig, K.A., Penix, T.M. & O’Donohue, W. (2002). Relapse Prevention Encyclopaedia of Psychotherapy 1st Edition. Edited by Hersen M, Sledge W Elsevier.

Flores, P.J. (1977). Group Psychotherapy with Addicted Populations: An Integration of Twelve Step and Psychodynamic Theory. 2d ed. New York: The Haworth Press.

Irvin, J.E., Bowers, C.A., Dunn, M.E., & Wang, M.C. (1999). Efficacy of relapse prevention: a meta-analytic review. Journal of Consulting and Clinical Psychology, 67 (4), 563-70.

Kirshenbaum, A., Olsen, D.M. & Bickel, W.K. (2009). Quantitative review of the ubiquitous relapse curve. Journal of  Substance Abuse Treatment, 36 (1), 8–17 .

Marlatt, G.A., & Witkiewitz, K. (2005).  Relapse prevention in Alcohol and drug problems Relapse Prevention: Maintenance Strategies in Treatment of Addictive Behaviours 2nd Edition. Edited by Marlatt GA, Donovan DM Guilford Press.

McCrady BS. Alcohol use disorders and the Division 12 Task Force of the American Psychological Association Psychology of Addictive Behaviors 2000, 14 (3), 267-276.

Miller, W., & Hester, R. (1980). Treating the problem drinker: modern approaches. In: Miller WR, ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking and Obesity. New York, NY: Pergamon Press. 

Steckler, G., Witkiewitz, K., & Marlatt, G.A. (2013). Relapse Prevention Principles of Addiction Vol 1 1st Edition Edited by Miller PM Elsevier.

Vannicelli, M.  (1992). Removing the Roadblocks: Group Psychotherapy with Substance Abusers and Family Members. New York: Guilford Press.

meta-analytic review. Journal of Consulting and Clinical Psychology, 67 (4), 563-70.

Kirshenbaum, A., Olsen, D.M. & Bickel, W.K. (2009). Quantitative review of the ubiquitous relapse curve. Journal of  Substance Abuse Treatment, 36 (1), 8–17 .

Marlatt, G.A., & Witkiewitz, K. (2005).  Relapse prevention in Alcohol and drug problems Relapse Prevention: Maintenance Strategies in Treatment of Addictive Behaviours 2nd Edition. Edited by Marlatt GA, Donovan DM Guilford Press.

McCrady BS. Alcohol use disorders and the Division 12 Task Force of the American Psychological Association Psychology of Addictive Behaviors 2000, 14 (3), 267-276.

Miller, W., & Hester, R. (1980). Treating the problem drinker: modern approaches. In: Miller WR, ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking and Obesity. New York, NY: Pergamon Press. 

Steckler, G., Witkiewitz, K., & Marlatt, G.A. (2013). Relapse Prevention Principles of Addiction Vol 1 1st Edition Edited by Miller PM Elsevier.

Vannicelli, M.  (1992). Removing the Roadblocks: Group Psychotherapy with Substance Abusers and Family Members. New York: Guilford Press.

Conflict of interest: None
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